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Background: Despite evidence of the overuse of acid suppressive medication for gastroesophageal reflux disease (GERD), a transfer to noncontinuous therapy after long-term treatment proves difficult., Aim: To quantify the effect of blinded dosage reduction after long-term therapy on symptom control and quality of life while assessing pharmacological and placebo needs., Methods: Primary care patients with a history of GERD and long-term treatment were randomized to daily placebo with pantoprazole rescue (n = 141) or daily pantoprazole with placebo rescue (n = 62) upon relief after 4 weeks pantoprazole 20 mg. The number of rescue tablets, symptom control and generic quality of life were analyzed., Results: Measured from the daily placebo arm, 19% of the patients terminated treatment, 33% managed with 2-6 tablets/week, 38% needed a daily dosage and 10% needed more than a daily dosage in the long run. At these final dosages, symptom control and quality of life were dosage-independent and, furthermore, equal to values of patients on fixed daily pantoprazole. A temporal decrease in well-being was seen in 24% of the patients., Conclusion: A significant placebo response is apparent in long-term users of acid suppressive medication and pharmacological dependency is overestimated. Despite their history of long-term treatment, the majority of GERD patients can be switched from daily to on-demand treatment without impairing symptom control and quality of life., (Copyright 2009 S. Karger AG, Basel.)

Aim: The aim of this study was to explore determinants of residual reflux symptoms among patients with gastroesophageal reflux disease (GERD) despite maintenance treatment with acid suppressive medication (ASM)., Methods: Primary care GERD patients on chronic ASM were classified as symptom-free (55%) or symptomatic (45%) according to the impact of their residual reflux symptoms (QolRad). They were compared with respect to lifestyle (BMI, alcohol, smoking, physical exercise), compliance (daily ASM dosage), disease history, psychological factors (SCL-90) and quality of life (SF-36)., Results: None of the investigated lifestyle factors, nor dosage and disease history were related to residual symptoms. However, symptomatic patients differed from patients with relief on all psychological and quality of life dimensions. In a multiple logistic regression model somatization, hostility, mental health, body pain, as well as gender were independently associated with residual symptoms; the derived ROC curve had an AUC of 0.78., Conclusions: The majority of GERD patients is symptom-free on chronic ASM; they display a healthy psychological state and high quality of life. Residual symptoms however, are associated with psychological distress and lower quality of life. Recognition of this subgroup might hold the key to improving long-term management of gastroesophageal reflux., (Copyright 2008 S. Karger AG, Basel.)

Aim: To assess the diagnostic accuracy of the proton pump inhibitor test in a primary care population as well as its additional value over reflux history, using the symptom association probability outcome during 24-h oesophageal pH recording as reference test for gastro-oesophageal reflux disease., Methods: Subjects with symptoms suggestive of gastro-oesophageal reflux disease were recruited from primary care. After a 24-h pH recording with calculation of the symptom association probability, subjects started using 40 mg esomeprazole once daily for 13 days. The proton pump inhibitor test was considered positive when the subjects reported adequate symptom suppression. Data are presented as means with 95% confidence intervals., Results: Successful 24-h pH recording was accomplished in 84 of the 90 subjects, while the symptom association probability was calculable in 74. The symptom association probability was positive in 70% of the subjects. The sensitivity of the proton pump inhibitor test was 0.91 (CI 0.78-0.96) and the specificity was 0.26 (CI 0.10-0.49). The mean likelihood ratio was 1.2 (CI 0.9-1.6) with little variation over the 13 consecutive proton pump inhibitor test days. The likelihood ratios of gastro-oesophageal reflux disease symptoms were comparable, ranging around 1., Conclusions: In primary care patients with reflux symptoms gastro-oesophageal reflux disease is highly prevalent. Under these conditions the additional value of short-term treatment with a proton pump inhibitor for diagnosing gastro-oesophageal reflux disease is limited.

Objective: The findings of several studies suggest that proton-pump inhibitors (PPIs) suppress gastric acid more effectively in Helicobacter pylori-infected (Hp +) than in non-infected (Hp -) patients, but there has been no evaluation of the short-term clinical response., Material and Methods: Results of the first week of treatment with rabeprazole in Hp+ and Hp- patients with gastroesophageal reflux disease (GERD) were compared in a large prospective open-label, multicenter, cohort study in general and specialized practices. GERD patients were recruited on the basis of either typical symptoms alone or endoscopic results, assessed for H. pylori infection and treated with rabeprazole (20 mg). Heartburn and regurgitation symptoms were assessed daily during the first 7 days. Outcome parameters were calculated for both symptoms and compared between Hp+ and Hp- patients., Results: Data on 1548 patients (74.5% Hp-, 25.5% Hp + ) were available. Mean heartburn and regurgitation scores decreased during the first week. For both symptoms, more than 70% of the patients had "adequate" symptom relief at day 5, and more than 80% at day 7. "Complete" symptom relief was reached in more than 70% of patients. Mean onset of adequate symptom control was about 4 days. In Hp+ and Hp- patients there was no difference in response for any of the parameters., Conclusions: Among patients treated with rabeprazole in clinical practice, H. pylori infection or its absence has no effect on the speed or degree of GERD symptom relief. Infected patients and non-infected patients can therefore be treated with a similar dose. When treating heartburn with rabeprazole, physicians do not need to consider the patient's H. pylori status and most patients (>80%) have adequate symptom relief after just a few days of treatment.

Objective: To determine the value of successful trial therapy with proton-pump inhibitors (PPIs) as a diagnostic test for gastro-oesophageal reflux disease (GERD)., Design: Systematic review and meta-analysis., Method: Studies were included in which the clinical response to a short course (1-4 weeks) of PPI therapy could be related to abnormal results of 24-hr pH monitoring, gastroscopy, and/or diagnostic questionnaires. The sensitivity and specificity of the trial therapy were calculated. The ROC method was used to summarize the test characteristics across studies., Results: With 24-hr pH monitoring as the reference standard, the positive likelihood ratio of the diagnosis 'reflux disease' ranged from 1.63 to 1.87 and the combined estimates of sensitivity and specificity in the various studies were 0.78 (95% CI: 0.66-0.86) and 0.54 (0.44-0.65), respectively. These values were lower with the other reference standards., Conclusion: Although there were insufficient data to determine the effect of varying dosages of PPIs and duration of therapy on the test characteristics, successful short-term treatment with PPIs in patients suspected of having GERD provides insufficient certainty as to the diagnosis.

Background: Amongst primary care patients with dyspeptic symptoms, those with reflux-like symptoms or gastro-oesophageal reflux disease are expected to benefit most from empirical proton pump inhibitor therapy. Recognition of this patient group, however, is difficult. The Carlsson-Dent gastro-oesophageal reflux disease questionnaire was developed to justify the selection of primary care patients for empirical proton pump inhibitor treatment., Aim: To evaluate the diagnostic test characteristics of the Carlsson-Dent questionnaire in a primary care population., Methods: A prospective, open-label, multi-centre diagnostic prevalence study was conducted amongst primary care adults with reflux symptoms. All patients completed the questionnaire and underwent gastroscopy. If no abnormalities were found, the patients were prescribed 2 weeks of treatment with omeprazole (20 mg daily). Receiver operating characteristic curve analysis was used to determine the overall discriminative value of the questionnaire. Diagnostic test characteristics of both the cut-off score (total diagnostic score) in the questionnaire and the physician's provisional classification were measured using oesophagitis and omeprazole treatment success as the reference tests., Results: Of the 536 patients included, 515 underwent endoscopy. No abnormalities were found in 286 (55%). Omeprazole treatment success occurred more frequently in patients with a total diagnostic score of > 7 and oesophagitis II-IV in patients with a total diagnostic score of > 9. The diagnostic test characteristics of the questionnaire were comparable with those of the physician's provisional classification. The area under the receiver operating characteristic curve did not exceed 0.65. Kappa values for observer agreement with the gold standard were far below 0.4., Conclusion: The diagnostic performance of this version of the Carlsson-Dent questionnaire was poor. It equalled the physician's clinical judgement and therefore its value for clinical use is limited.

Objective: To derive and evaluate diagnostic determinants of gastro-oesophageal malignancy as a means of helping family physicians select patients for 'open-access' gastroscopy. In this multicenter study, 861 consecutive patients were investigated with first-time gastroscopy (study population). Another 1153 patients were studied during the next 6 years (validation population). General practitioners registered symptoms relevant to malignancy and patient histories; the results of gastroscopies were received from the endoscopists. Methods: Univariate and multivariate analyses resulted in four relevant symptoms that were then compared with 'alarm symptoms' previously published in the literature. Receiver-operating characteristic analysis was used to evaluate the probability of finding malignancy using these two sets of symptoms. Results: Positive answers regarding the symptoms, weight loss and dysphagia, together with negative answers on pain during the night and heartburn, predicted malignancy in the study population with an AUC (area under the curve) of 0.90. 'Alarm symptoms' performed less well in the study population (AUC 0.85), although reproducibility was better in the validation population (0.71 versus 0.63). If exclusion of malignancy had been chosen as the only valid reason for requesting gastroscopy, then pre-selection with the help of these symptoms would have reduced the number of requests by 10%. Conclusion: Thorough evaluation of 'classical' alarm symptoms in dyspeptic patients might help minimize unnecessary gastroscopy requests by GPs seeking a safe treatment decision. [ABSTRACT FROM AUTHOR]

Reports on the study conducted on the confirmation of gastroesophageal reflux disease (GERD). Backflow of stomach contents into esophagus; Importance of tests like pH monitoring, and endoscopy; Use of proton-pump inhibitors (PPIs) drugs for treatment; Conclusion that GERD cannot be confirmed on the basis of PPIs.

The article investigates the potential use of a proton pump inhibitor (PPI) as a diagnostic strategy to determine gastroesophageal reflux disease (GERD). A short course of PPI is often used to determine whether a patient with typical reflux symptoms truly has GERD. To evaluate the diagnostic accuracy of the PPI test, the researchers enrolled 74 patients with typical reflux symptoms. A positive response to the PPI test was considered to a symptom association probability less than 95 percent, a symptom index of less than 50 percent, and a symptom severity index of less than 10 percent. The results indicate the sensitivity of the PPI test was 91 percent.